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psnet.ahrq.gov/node/40951/psn-pdf
December 21, 2014 - Quality and safety in medical care: what does the future
hold?
December 21, 2014
Liang BA, Mackey T. Quality and safety in medical care: what does the future hold? Arch Pathol Lab Med.
2011;135(11):1425-31. doi:10.5858/arpa.2011-0154-OA.
https://psnet.ahrq.gov/issue/quality-and-safety-medical-care-what-does-future…
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psnet.ahrq.gov/node/43216/psn-pdf
June 25, 2014 - Banning the handshake from the health care setting.
June 25, 2014
Sklansky M, Nadkarni N, Ramirez-Avila L. Banning the handshake from the health care setting. JAMA.
2014;311(24):2477-8.
https://psnet.ahrq.gov/issue/banning-handshake-health-care-setting
Hand hygiene is an important practice that prevents transmissi…
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psnet.ahrq.gov/node/36810/psn-pdf
November 19, 2014 - A Systems Approach to Quality Improvement in Long-
Term Care: Safe Medication Practices Workbook.
November 19, 2014
Massachusetts Coalition for the Prevention of Medical Errors, MassPRO, Massachusetts Extended Care
Foundation. Boston, MA: Commonwealth of Massachusetts; 2008.
https://psnet.ahrq.gov/issue/systems-ap…
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psnet.ahrq.gov/node/45226/psn-pdf
January 04, 2017 - AHRQ Research Summit on Improving Diagnosis in
Health Care.
January 4, 2017
Rockville, MD; Agency for Healthcare Research and Quality: September 28, 2016.
https://psnet.ahrq.gov/issue/ahrq-research-summit-improving-diagnosis-health-care
Research is increasingly focusing on diagnostic errors and strategies to reduc…
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psnet.ahrq.gov/node/50667/psn-pdf
November 13, 2019 - Proactive prevention of maternal death from maternal
hemorrhage.
November 13, 2019
Quick Safety. October 29, 2019;(51):1-3.
https://psnet.ahrq.gov/issue/proactive-prevention-maternal-death-maternal-hemorrhage
The reduction of postpartum hemorrhage and the overall improvement of maternal safety is a patient safety
…
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psnet.ahrq.gov/node/39585/psn-pdf
June 09, 2010 - Bar code technology and medication administration error.
June 9, 2010
Young J, Slebodnik M, Sands L. Bar Code Technology and Medication Administration Error. J Patient Saf.
2010;6(2):115-120. doi:10.1097/pts.0b013e3181de35f7.
https://psnet.ahrq.gov/issue/bar-code-technology-and-medication-administration-error
This…
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psnet.ahrq.gov/node/61002/psn-pdf
September 17, 2020 - Patient Safety
September 17, 2020
Organisation for Economic Co-operation and Development.
https://psnet.ahrq.gov/issue/patient-safety-21
Organizations worldwide are focusing efforts on reducing the conditions that contribute to medical error.
This website provides a collection of reports and other resources that c…
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psnet.ahrq.gov/node/74766/psn-pdf
June 24, 2024 - Patient handoffs.
June 24, 2024
Arora V, Farnan J. UpToDate. June 24, 2024.
https://psnet.ahrq.gov/issue/patient-handoffs-0
The change of an inpatient’s location or handoffs between teams can fragment care due to communication,
information, and knowledge gaps. This review examines in-patient transition safety issu…
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psnet.ahrq.gov/node/48026/psn-pdf
July 10, 2019 - Network of Patient Safety Databases.
July 10, 2019
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/network-patient-safety-databases
The Patient Safety Organization (PSO) program seeks to gather and analyze nonidentifiable patient safety
incident data to track concerns and reduce risks. Thi…
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psnet.ahrq.gov/node/47348/psn-pdf
September 05, 2018 - Hospital-Acquired Condition Reduction Program
(HACRP).
September 5, 2018
QualityNet. Centers for Medicare and Medicaid Services.
https://psnet.ahrq.gov/issue/hospital-acquired-condition-hac-reduction-program
Eliminating hospital-acquired harm requires policy, organizational, and individual approaches to motivate
…
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psnet.ahrq.gov/node/39344/psn-pdf
March 03, 2010 - Mistake-proofing healthcare: why stopping processes
may be a good start.
March 3, 2010
Grout JR, Toussaint JS. Mistake-proofing healthcare: Why stopping processes may be a good start. Bus
Horiz. 2009;53(2):149-156. doi:10.1016/j.bushor.2009.10.007.
https://psnet.ahrq.gov/issue/mistake-proofing-healthcare-why-stopp…
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psnet.ahrq.gov/node/45932/psn-pdf
May 18, 2017 - Polypharmacy.
May 18, 2017
Zagaria MAE, ed. Clin Geriatr Med. 2017;33:153-292.
https://psnet.ahrq.gov/issue/polypharmacy
Older patients are likely to be prescribed multiple medications, which can increase risks. Articles in this
special issue explore polypharmacy in a variety of care settings and provide tactics f…
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psnet.ahrq.gov/node/50771/psn-pdf
May 29, 2024 - AHRQ Health Literacy Universal Precautions Toolkit. 3rd
edition.
May 29, 2024
Brach C, ed. Rockville, MD: Agency for Healthcare Research and Quality; March 2024. AHRQ Publication
No. 15-0023-EF.
https://psnet.ahrq.gov/issue/ahrq-health-literacy-universal-precautions-toolkit-2nd-edition
The AHRQ Health Literacy Un…
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digital.ahrq.gov/organization/upper-peninsula-health-care-network
January 01, 2023 - Upper Peninsula Health Care Network
Critical Access Hospital Partnership Health Information Technology Implementation - 2009
Principal Investigator
Wheeler, Donald
Project Name
Critical Access Hospital Partnership Health Information Technology Implementation
…
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www.ahrq.gov/hai/cauti-tools/archived-webinars/engaging-nurse-physician-patient-transcript.html
December 01, 2017 - choices, and communicate more effectively with providers, that open communication promotes efficiency, reduces
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/engaging-nurse-physician-patient-transcript.docx
June 02, 2025 - choices, and communicate more effectively with providers, that open communication promotes efficiency, reduces
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psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error
February 01, 2012 - Febrile Neutropenia and an Almost Fatal Medication Error
Citation Text:
Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/operational-adjustments-event-summary.pdf
July 02, 2020 - 1
Learning Community Affinity Group
Summary-at-a-Glance:
Operational Adjustments while Resuming In-Person Cardiac
Rehabilitation Programs
July 2, 2020
Event Purpose and Overview
• Purpose: To share and acquire strategies for how to adjust operations while resuming in-person
cardiac rehabilitation p…
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www.ahrq.gov/ncepcr/reports/2025-annual-report/health-disparities.html
August 01, 2025 - AHRQ’s Investments in Primary Care Research for 2023 and 2024
Health Disparities
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Table of Contents
AHRQ’s Investments in Primary Care Research for 2023 and 2024
Acknowledgements and Authors
Message from the Director of AHRQ’s National Center for Excellence in Primary Ca…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-6.html
September 01, 2021 - The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science
References
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Table of Contents
The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: Stat…